<?xml version="1.0" encoding="UTF-8" ?> 

<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.01 Transitional//EN">

<html>

    <head>
	<meta http-equiv="Content-Type" content="text/html;charset=UTF-8" />        
	<title>Tarifa Social</title>
	<link rel="stylesheet" type="text/css" href="style.tarifasocial.css" media="screen,projection" />
    </head>

    <body>
	<wicket:extend>
	    <table width="100%">
		<tr>
		    <td>
                        <h2>Registro - Formulario de Solicitud de Usuario</h2>
                    </td>
		</tr>
	    </table>
	    <br>
	    
	    <form wicket:id="formRegistration">
		<table width="100%">
		    <tr>
			<td width="25%" align="right">Nombre(s)</td>
			<td align="left">
			    <input type="text" wicket:id="name" class="text2" size="50" maxlength="50">
			</td>
		    </tr>
		    <tr>
			<td align="right">Apellido</td>
			<td align="left">
			    <input type="text" wicket:id="lastName" class="text2" size="30" maxlength="50">
			</td>
		    </tr>
		    <tr>
			<td align="right">Nombre de usuario</td>
			<td align="left">
			    <input type="text" wicket:id="userName" class="text2" size="15" maxlength="100">
			</td>
		    </tr>
		    <tr>
			<td align="right">Contraseña</td>
			<td align="left">
			    <input type="password" wicket:id="password" class="text2" size="15" maxlength="100">
			</td>
		    </tr>
		    <tr>
			<td align="right">e-mail</td>
			<td align="left">
			    <input type="text" wicket:id="email" class="text2" size="50" maxlength="100">
			</td>
		    </tr>
		    <tr>
			<td align="right">Institución</td>
			<td align="left">
			    <input type="text" wicket:id="company" class="text2" size="50" maxlength="100">
			</td>
		    </tr>
		    <tr>
			<td align="right">Cargo</td>
			<td align="left">
			    <input type="text" wicket:id="companyPosition" class="text2" size="50" maxlength="100">
			</td>
		    </tr>
		</table>
		<br>
		
		<input type="submit" value="Enviar solicitud" class="text2">
	    </form>
	    
	</wicket:extend>
    </body>
</html>